Pneumonia management
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Pneumonia
Dr Swati Das
Consultant Pulmonologist
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Radiological Clinical
Is It Pnemonia?
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Pneumonia is an acute infection of lung parenchyma
Can be subdivided into different types according to epidemiological criteria
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Epidemiological classification of Pneumonia
CAP: Community Acquired Pneumonia
HCAP: Health Care Associated Pneumonia
HAP or NP: Hospital Acquired Pneumonia
VAP: Ventilator Associated Pneumonia
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Unknown in the most of countries
5-11/1000 adults in US & UK*
*Eur Respir Mon, 2009, 43, 111–132
Incidence of CAP
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Pneumonia: a difficult diagnosis ?
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Mr. SM
69 years
Does not smoke (anymore since two years)
No co-morbids
Cough since five days
Coughs up some green phlegm
Looks unwell
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Pulse 92 reg
BP 130/90mm Hg
RR 20/min
Temp 38.5 C
Percussion: normal
Auscultation: some scattered rhonchi
Mr. SM
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Diagnosis?
Acute bronchitis
Pneumonia
Exacerbation COPD
Mr. SM
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Aetiology Bacterial
Viral
Tumor
Cardiac
Signs & symptoms Cough
Fever
Crackles
Rales
Diagnosis Bronchitis
COPD
Heart failure
Pneumonia
Lung cancer
Nothing specific
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Searching for the correct diagnosis
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Questions on diagnosis
How to detect pneumonia?
Diagnostic value of signs and symptoms ???
Additional value of tests?
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Most important tests
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Diagnostic models
• Hopstaken et al
•Dry cough, diarrhoea, temp > 38 C
•If all three present: 76% CAP, if none present: 6%
• Diehr et al
•Absence of rhinorrhoea and sore throat, presence of night sweats,
myalgia, sputum all day, resp rate > 25, fever
• Score 1: 9% CAP, score 4, 27%, score 6 100%
• Khalil et al
•Cough, chest pain, shortness of breath, temp>38, heart rate>100,
Resp rate>20, pulse oximetry<95%
•Pos pred value 30%, neg pred value 99%
• Gonzales Ortiz et al
• pathologic auscultation, neutrophilia, pleural pain, dyspnoea
• pos pred value 23%, neg pred value 88%
• Melbye et al
• Absence of coryza and sore throat, presence of dyspnoea, chest pain, crackles
•Pos pred value 17%, neg pred value 79%
Not Of help
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Additional tests
Radiological investigations
Tests to detect bacterial pathogens
Gram stain, sputum c/s, blood c/s
Urine test for Streptococcus pneumoniae
sen>70%,specificity>95%,
Legionella antigen
Tests to detect viral pathogens
Test for influenza
Biomarkers
CRP
Procalcitonine/adrenomodulin
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AD, 50 ys
Hello doctor, … I’ve got fever and dry cough since two
days
BP 120/70 HR 88r RR 18’ TEMP 39.0°C
Breath sound diminished on right base
HOSPITAL ADMISSION?
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1. No, mild clinical syndrome
2. Yes, high fever
3. What about history?
Hospital admission?
Otherwise healthy man
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1. No, mild clinical syndrome in otherwise healthy man
Hospital admission?
Pneumonia = 4 medium risk = 10%
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• Fever (38.5°C) 2days
• Dry cough 3days
• Physical examination:
• non-ill; BP 130/80 HR 96r RR 20’
• rales right lung base
DFE, 34
Chest x-ray
You - his physician –
decide …
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… to hospitalise him
WHY?
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History is lacking:
the patient underwent splenectomy 2 years before
He is immunocompromised
at risk for development of severe fulminant sepsis
(especially by S. pneumoniae and H. influenzae)
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• Fever (37.7°C) started one day before
• non-productive cough
• Non-ill; BP 120/85 HR 90 RR 20’
• Co-morbids-DM, CHF;
FP, 81 ys
What would you do?
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1. admit to hospital
2. treat him as outpatient
FP, 81 ys
admit to hospital: patient at risk for adverse outcome
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Pneumonia + age + CHF + DM = 9 complications risk = 31%
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•Fever (37.9°C) started two days before
• non-productive cough
DA, 63 ys
You - his physician - decide that your patient
is a candidate for hospital admission
Why?
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• Fever (37.9°C) started two days before
• non-productive cough
DA, 63 ys, otherwise healthy
The speech is interrupted by frequent breaths
Hello doctor I’ve got fever and dry cough since two days
breath breath breath breath breath
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•Analysis performed on 1343 patients (208 out-patients and 1135 hospitalized)
with all data sets completed for the calculation of CURB, CRB and CRB-65
•Validated in 1967 patients (482 out-patients and 1485 hospitalized)
Bauer TT et al. J Intern Med. 2006; 260:93-101
CRB-65 predicts death from community-acquired pneumonia
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CURB–65 score
Score one point for presence of each Clinical feature (0 –
5)
1. Confusion
2. Urea > 7 mmol/l
3. Respiratory rate 30/min
4. Blood pressure (SBP <90 or DBP 60mmHg)
5. Age 65yrs
(Albumin < 30 g/dl had an OR 4.7 [2.5-8.7] <0.001)
Lim et al Thorax 2003;58:377-382
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CURB 65
0-1=Outpatient
2=Hospital
>=3 HDU/ICU
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CONCLUSIONS: Both the CURB and CRB-65 scores can be used in the hospital and
out-patients setting to assess pneumonia severity and the risk of death
Given that the CRB-65 is easier to handle, we favor the use of CRB-65 where blood
urea nitrogen is unavailable Bauer TT et al. J Intern Med. 2006; 260:93-101
RESULTS: Overall 30-day mortality was 4.3% (0.6% in out-patients and 5.5% in hospitalized patients,
p<0.0001). Overall, the CURB, CRB and CRB-65 scores provided comparable predictions for death from CAP
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SCAP score
Major
Arterial pH <7.30 — 13 points
Systolic blood pressure <90 mmHg — 11 points
Minor
RR >30 breaths/min — 9 points
PaO2/FIO2 <250 mmHg — 6 points
BUN >30 mg/dL (10.7 mmol/L) — 5 points
Altered mental status — 5 points
Age ≥80 years — 5 points
Multilobar/bilateral infiltrates on x-ray — 5 points
>=10 severe CAP
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EMPIRIC TREATMENT?
YES !!! Based on knowledge….
…..You need to know
Epidemiology in YOUR area
Rate of antibiotic resistance in YOUR area
Please do not forget Microbiology work
up……
EVEN IF IT COSTS….
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Factors in empirical antibiotic choice for CAP
GEOGRAPHY
Spectrum of causative pathogen Acquired antibiotic resistance THE PATIENT Illness severity Other characteristics (eg age, vomiting) THE ANTIBIOTIC Randomised controlled trial Drug side effects Cost
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0 10 20 30 40
S pneumoniae
H influenzae
Legionella
Staph aureus
GNEB
%
UK Europe AUS + NZ N America
GEOGRAPHICAL VARIATION IN
CAP (32 prospective studies; n = 8211)
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0 5 10 15 20
M pneumoniae
C pneumoniae
C psittaci
C burnetii
Viruses
%
UK Europe AUS + NZ N America
GEOGRAPHICAL VARIATION IN
CAP (32 prospective studies; n = 8211)
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S pneumoniae
H influenzae
Mycoplasma
Chlamydia
Legionella
Gram-negative
bacteria
B-lactam
Macrolide
Tetracycline
Fluoroquinolone
Cephalosporin
ANTIBIOTIC THERAPY
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Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72
ATS/IDSA
INPATIENT – NON-ICU
Fluoroquinolone (strong recommendation; level I evidence)
-lactam + macrolide
(strong recommendation; level I evidence)
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Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72
ATS/IDSA GUIDELINES
INPATIENT – ICU
-lactam +
Either Azithromycin (level II evidence)
or Fluoroquinolone (strong recommendation; level I evidence)
For Pseudomonas
Anti-pseudomonal -lactam +
Either cipro or levo (level II evidence)
or above -lactam + gentamicin + azithromycin
or above -lactam + antipneumococcal fluoroquinolone
(weak recommendation; level III evidence)
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34 yrs, Chinese; ER visit for fever and blood-tinged sputum
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Risk factors for TB
Yes/No
IF YES NO QUINOLONES
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Antibiotic within 6 hours and oxygen therapy
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Conclusion
Clinical assessment
Know your local epidemiology
Be aware of national and international outbreaks
Never forget Mycobacterium tuberculosis
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